stomach: 1. peptic ulcer (?NSAID) 2. GORD (better w antacids) 3. gastritis (retrosternal, ETOH) 4. malignancy (weight loss) ``` pancreas: acute pancreatitis (?Gallstones, high amylase) ``` above (heart): MI below (aorta): ruptured aaa right (liver/gallb): 1. choleycstitis 2. hep

Interactive gastrointestinal cases - amir sam Flashcards by J Akoro

Inspection of hands (abcdefgh)

a. Asterixis (liver flap)
b. Bruising
c. Clubbing
d. Dupuytren’s contracture
e. Erythema
f. Fetor (smell)
g. Gynaecomastia
h. Hair loss
i. Icteris
j. Jaundice
k. Leuconychia - low albumin

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inspection of arms

av fistula

current or prevous renal replacement therapy

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inspection of head and neck

anaemia
jaundice
skin: jaundice, excoriation marks (itching) or spider naevi (press let go, fills from centre)
oral: Pigmentation or Gum hypertrophy (? on ciclosporine after renal transplant)

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inspection of chest

a. Gynaecomastic, hair loss, excoriation, spider naevi

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inspection of abdomen

a. Abdominal distension

b. Caput medusae (portal hypertenion): recanalisation of umbilical vein
i. Distended superficial abdominal veins
ii. Direction of flow in the veins below the umbilicus is towards the legs

c. Scars

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causes of hepatomegaly

cancer
cirrhosis
cardiac - congestive cardiac failure, Constrictive pericarditis : high JVP, ascites
infiltration - FLASH
a) Fat
b) Haemochromatosis
c) Amyloidosis
d) Sarcoidosis
e) Lymphoproliferative diseases

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causes of liver diseases

Alcohol
Autoimmune
Drugs
Viral
Biliary disease

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causes of splenomegaly

H: portal hypertension
H: haematological
Infection
Inflammation

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classifying ddx of gi

abdo pain, abdo distension, change of bowel habit, gi bleed, jaundice, ascites

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case: epigastric pain that radiates to the pain. haemodynamically compromised (low bp)

ruptured aortic aneurysm

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abdominal pain nature types n causes

Constant: inflammation e.g. cholecystitis

Colicky: bowel obstruction, stone

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medical causes of acute generalised abdo pain

DKA, addisonians crisis, hypercalcaemia, porphyria, lead poisoning

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epigastric pain ddx

stomach:

peptic ulcer (?NSAID)
GORD (better w antacids)
gastritis (retrosternal, ETOH)
malignancy (weight loss)

pancreas:
acute pancreatitis (?Gallstones, high amylase)

above (heart): MI

below (aorta): ruptured aaa

right (liver/gallb): 1. choleycstitis
2. hep

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acute pancreatitis presentation

pain and high amylase/lipase

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chronic pancreatitis presentation

pain, wt loss, 2. loss of exocrine function -steatorrhoea
Loss of endocrine function - diabetes
Normal amylase
Faceal elastase

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RUQ pain ddx

GB: cholecystitis, cholangitis, gallstones

liver: hepatitis, abscess
above: basal pneumonia
below: appendicitis (long retrocaecal appendix inflamed)
left: peptic ulcer, pancreatitis, Meckels diverticulum?
right: kidney - pyelonephritis

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RIF pain ddx

GI: appendicits, mesenteric adenitis (children) - look at lymph nodes on US, colitis IBD, malignancy

Gynae: ovarian cyst rupture/twist/bleed, ruptured ectopic pregnancy

kidney stones, diverticulitis (caecal)

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suprapubic pain ddx

cystitis and urinary retention

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LIF pain ddx

diverticultis, colitis (IBD), malignancy

ovarian cyst rupture, twist bleed. ectopic pregnancy

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diffuse abdominal pain ddx

obstruction
infection - peritonitis, gastroenteritis
inflammation - ibd
ischaemia - mesenteric ischaemia

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leaking aaa repair blood tests:

high lactate - hypoperfusion
low bicarbonate - acidotic
high amylase - goes up in any cause of acute abdomen

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what is spontaneous bacterial peritonitis

more than 250 neutrophil cells/mm^3

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abdominal distention - fluid clues

ascities: shifting dullness, signs of liver disease

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abdominal distention - flatus clues

Obstruction:

Nausea, vomiting
Not opened bowel - ask about last time
High pitched tinkling BS
?Previous surgery (adhesions)
?Tender irreducible femoral hernia in groin

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how is ascites classified

transudate <30 or exudate >30

causes of transudate ascites

1. Cirrhosis 2. Cardiac failure 3. Nephrotic syndrome

causes of exudate ascites

1. Malignancy is more common (abdo, pelvic, peritoneal mesothelioma) 2. Infection e.g. TB, pyogenic 3. Budd Chiari syndrome: hepatic vein thrombosis, Portal vein thrombosis

cause of pale stool

stone blockage stops conjugated bilirubin from entering duodenum so there is low/no stercobilinogen

causes of prehepatic jaundice

haemolysis (spleen), defective conjugation - low glucuronidation (Gilberts)

causes of hepatic jaundice

hepatitis - alcohol, autoimmune, drug, viruses

cause of post hepatic jaundice

CBD obstruction (gallstone CBD, cancer in head of pancreas, stricture)

cause of dark urine

Leakage of conjugated bilirubin into blood from damaged hepatocytes

hb down and bilirubin up

sign of haemolysis

what symptoms are in both hepatic and post hepatic jaundice

dark urine and pale stool

painless jaundice diagnosis

pancreatic cancer

what will liver function tests show in obstruction (post hepatic jaundice)

high alp

what is a tumour marker for pancreatic cancer

Ca19-9

when is AST raised

damaged hepatocytes

bloody diarrhoea ddx

infective colitis, inflammatory colitis, | ischamic colitis, diverticultis, malignancy

causes of infective colitis

``` CHESS 1. Campylobacter 2. Haemorrhagic E.coli 3. Entamoeba histolytica 4. Salmonella 5. Shigella Send cultures for microscopy, culture, sensitivity, C.diff toxin ```

who is inflammatory colitis more common in

young people

what are some extra gi manifestations

- Ulcers - Clubbing - Scleritis - red eyes - Arthritis - Erythema nodosum - tender lesions on legs

who is ischaemic colitis more common in and how to investigatw

elderly, imaging, lactate and ck bloods

how to investigate inflammatory colitis

colonoscopy, mucus

abdominal x ray

1) Thumb prints - thickened haustral folds, bowel wall thickening 2) Featureless colon - IBD 3) Toxic megacolon - > 6cm a) Fluids, hydrocortisone, abdominal x-ray to detect toxic megacolon, call the surgeon's due to perf risk 4) Diarrhoea - Overflow spurious diarrhea due to faecal loading

management of acute gi bleed

1. ABC 2. iv access 3. fluids 4. G&S , X-match blood 5. OGD when stable

how to manage varciceal bleed

1) Abx - Reduces mortality | 2) Terlipressin injection-Splanchnic constrictor, vasopressin analogue

investigations for acute abdomen

FBC (anaemia), U+E (renal), LFTs, CRP, Clotting, G+S, x-match - Erect CXR (perforation) - CT

what LFTs go up in hepatic jaundice

AST and ALT

management of acute abdomen

- NBM (nil by mouth) - Fluids - Analgesics - Anti-emetics - Abx: cefuroxime, metronidazole - Monitor vitals and UO

investigations for jaundice

1. Bloods: FBC, LFT, CRP | 2. Abdo US - After a fast - gallstones better visualised in a distended, bile filled GB

investigations for dysphagia and weight loss

OGD and biopsy

investigations for PR bleed and weight loss

colonoscopy

management plan for ascites patient

Tap + send, Drain, Monitor 1. Diuretics: spironolactone (blocks secondary hyperaldosteronism) ± frusemide only if peripheral oedema 2. Dietary sodium restriction 3. Fluid restriction in patients with hyponatraemia 4. Monitor weight daily 5. Therapeutic paracentesis: with IV human albumin

where do samples go to

1. Chemistry: BM, protein 2. Microscopy, culture, sensitivities 3. Cytology: malignant cells

management of encephalopathy

1) Lactulose 10ml TDS: stimulate bowel movement - osmotic a) Reduces transit time b) Less time for bacteria to work and make toxic products 2) ± Phosphate enemas 3) Avoid sedation 4) Treat infections: sepsis makes encephalopathy worse 5) Exclude a GI bleed

if serum albumin - ascites albumin is >11g/L what is the cause

cirrhosis, cardiac failure because the albumin in the ascites is low

if serum albumin - ascites albumin is >11g/L what is the cause

TB, cancer, nephrotic syndrome | high albumin in ascites due to infection.

post op care complications

wound infection, anastomotic leak and pelvic abscess - post appendectomy

features of a wound infection

erythematous, discharge

features of anastomotic leak

diffuse abdo pain, guarding, rigidity, hypotensive, tachycardic

features of pelvic abscess

pain, fever, sweats, mucus diarrhoea

presentation and treatment of perianal abscess

tender, red swelling. | incision and drainage

presentation and treatment of anal fissure

-Rectal pain on defecation and Stool coated with blood Advice RE diet (fluids, fibre), GTN: relaxation effect

presentaton of ibs

recurrent abdo pain, bloating , improves w defecation, change in freq/form of stool, no pr bleed, anaemia, wt loss or nocturnal symptoms, exclude coeliac

treatment of ibs

diet n lifestle modification. symptomatic rx: abdo pain - antispasmodics, laxatives and anti-diarrhoeals

ddx of ibs

malignancy and coeliac